Provider Demographics
NPI:1447234984
Name:KNUDTSON, KENNETH J (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:J
Last Name:KNUDTSON
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:2311 YORKSHIRE DRIVE
Mailing Address - Street 2:STE C
Mailing Address - City:BROOKINGS
Mailing Address - State:SD
Mailing Address - Zip Code:57006-2446
Mailing Address - Country:US
Mailing Address - Phone:605-692-7315
Mailing Address - Fax:605-692-2615
Practice Address - Street 1:2311 YORKSHIRE DRIVE
Practice Address - Street 2:STE C
Practice Address - City:BROOKINGS
Practice Address - State:SD
Practice Address - Zip Code:57006-2446
Practice Address - Country:US
Practice Address - Phone:605-692-7315
Practice Address - Fax:605-692-2615
Is Sole Proprietor?:No
Enumeration Date:2005-11-29
Last Update Date:2009-07-01
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Provider Licenses
StateLicense IDTaxonomies
SD4922207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6300590Medicaid
SD6300590Medicaid
SD8181Medicare ID - Type Unspecified